BEREAVEMENT BY TRAUMATIC MEANS: THE COMPLEX SYNERGY OF TRAUMA AND GRIEF

Mass Trauma, Multiple Losses, and the Application of the Two-Track Model of Bereavement in the Context of War: Assessment From a Systemic-Ecological Perspective

Multiple losses in wartime, both death-related and non-death-related, require multidimensional assessment to encompass both the event and the multiple levels of interpersonal and societal involvements within which individuals are embedded. We present a case study in which the traumatic death of a family member is a central, but not exclusive, element in understanding the bereavement process. The traumatic death originated with the events of October 7, 2023 and the ensuing war which were part of an overwhelming surge of traumatic losses in Israel. The bereaved's response met the criteria for Post-Traumatic Stress Disorder (PTSD) and Prolonged Grief Disorder (PGD). We recommend that multiple losses and their unique significance for the bereaved should be directly addressed in the assessment and formulation of therapeutic interventions. Therefore, we propose an approach to clinical assessment in cases of mass trauma and multiple losses, grounded in the Two-Track Model of Bereavement and the Systemic-Ecological Perspective.

Israeli mental health in the aftermath of the October 7 terrorist attack: risks, challenges, and recommendations

BACKGROUND

The October 7, 2023 terrorist attack and subsequent war in Israel have created an unprecedented mental health crisis. This commentary examines emerging data on the psychological impact of these events and argues for a paradigm shift in the Israeli mental healthcare system.

MAIN BODY

Recent studies reveal a dramatic increase in PTSD, depression, and anxiety among the Israeli populace. These findings underscore the long-lasting and pervasive nature of psychological trauma. Certain populations are disproportionately affected: women, ethnic minorities (particularly Israeli Arabs, who comprise 18.1% of the population), and those experiencing traumatic loss, displacement, or economic hardship. These groups require prioritized and tailored interventions. While existing outcome research provides a solid foundation for treating common trauma-related disorders like PTSD, depression, and anxiety, the Israeli mental health system is ill-equipped to handle the surge in demand. Too many clinicians lack training in evidence-based trauma therapies and standardized assessments. To address this gap, we advocate a system-wide transformation. This involves widespread training in evidence-based assessments and time- limited therapies, a focus on precision psychiatry tailored to individual needs, and the implementation of task-shifting and task-sharing models to expand access to care.

CONCLUSION

These strategies are crucial for mitigating the long-term mental health consequences of the October 7th attacks and fostering individual and societal resilience. Failure to act decisively will exacerbate the existing crisis, placing further strain on individuals, families, and Israeli society as a whole.

Examining worry and secondary stressors on grief severity using machine learning

BACKGROUND & OBJECTIVES

Worry and loss-related secondary stressors appear to be important correlates of problematic grief responses. However, the relative importance of these variables in the context of established correlates of grief responding, ranging from indicators of identity disruption and demographic characteristics of the bereaved to characteristics of the loss of quality of the relationship with the deceased, is unknown. Modeling the relative associations of these factors can be problematic, given the high degree of collinearity between these variables. This study used a machine learning approach to provide accurate estimations of the relative importance of these correlates for post-loss symptom severity.

METHODS AND RESULTS

A convenience sample of 428 bereaved people who had lost a parent, spouse, or child in the last 30 to 365 days completed an online survey. Random forest regression modeling examined the effects of worry and secondary stressors on symptom severity in the context of established correlates. Results indicated worry and the number of secondary stressors experienced were among the factors most strongly associated with severity of grief, depression, posttraumatic stress and problems functioning.

CONCLUSIONS

These results also provide insight into the relative importance of worry and secondary stressors affecting grief severity to guide future research.

An Analysis of Factors Predicting Post-Traumatic Stress Disorder and Grief Following Comrade Loss

This study explored how "inhibiting factors" associated with military-bereavement impact combatants' psychological sequelae following comrade loss. One hundred six eligible Israeli combat male-soldiers completed the Texas-Revised-Inventory of Grief, the post-traumatic-stress-disorder symptoms scale (PSS), the Male Role Norms Scale, the Social Acknowledgment Questionnaire, and a scale assessing Military Encouragement to Grieve (MEG-8). Time since loss had no impact on soldiers' levels of PSS or prolonged grief. Regression analysis indicated that higher masculinity-perception and disapproval from the family predicated higher PSS, above and beyond grief. Conversely, lower disapproval from the family, and higher disapproval from the general community, predicted higher grief, above and beyond PSS. Also, military encouragement significantly mediated the positive relationship between masculinity and sense of social-recognition. The results show how inhibiting factors contribute differently to the perpetuation of PSS and grief. This interplay sheds light on soldiers' "external" and "internal" loss processes of traumatic bereavement. The practical implications to treatment are also discussed.

Latent classes of acute grief reactions in the shadow of collective trauma and its predictors in bereaved adults

The current study explored grief reaction profiles after the October 7th, 2023, Israeli massacre regarding the loss of significant others. It investigated factors worsening pre-existing grief in 2,028 adult civilians, with 1,263 reporting pre- or post-massacre loss. Participants completed self-reports on prolonged grief disorder (PGD), post-traumatic stress disorder (PTSD), complex PTSD (CPTSD), cognitive emotional regulation (CER), and assumptive worldviews. Latent class analysis identified four classes of probable PGD among those with lifetime loss: "high PGD-both core and emotional pain" (35.9 %); "Medium PGD-emotional pain" (6.9 %); "medium to high PGD-high core, medium emotional pain" (23 %); and "low PGD-both core and emotional pain" (34.5 %). The subsample analysis of individuals experiencing lifetime loss with concurrent October 7th loss indicated three classes of probable PGD: "high PGD symptoms" (47.9 %), "high to medium PGD-high core with medium emotional pain symptoms" (15.9 %), and "low PGD symptoms" (36.2 %). The subsample analysis of those who experienced concurrent recent loss related to the October 7th attack showed two classes related to indicative of acute grief: "high PGD symptoms" (69 %), and "low PGD symptoms" (31 %). Negative CER coping strategies were associated significantly with the high PGD in all three groups, and with increased risk of PTSD and CPTSD symptoms compared to the "low PGD symptoms" group. Collective bereavement amid collective trauma can activate prior individual grief reactions, even without current losses from the traumatic event. Those experiencing loss tied to severe traumatic events may face higher susceptibility to developing pathological grief.

A functional approach to defining and repairing moral injury: Evidence, change agents, clinical strategies, and lessons learned

This is a conceptual overview of a premeeting institute (PMI) I presented at the 39th International Society for Traumatic Stress Studies (ISTSS) annual meeting in November 2023 entitled, "A Functional Approach to Repairing Moral Injury and Traumatic Loss in Context: Evidence, Change Agents, Clinical Strategies, and Lessons Learned." This paper was invited by the co-chairs of the Scientific Program Committee, Isaac Galatzer-Levy and Katharina Schultebraucks. I first describe the aims of the PMI and then summarize the foundational assumptions that led me to expand adaptive disclosure and create adaptive disclosure-enhanced (AD-E). The foundational assumptions are that (a) moral injury is a unique measurable potential clinical problem, (b) moral injury damages the sustaining building blocks to personal and collective humanity, and (c) repairing moral injury requires corrective humanizing and virtuous experiences and connections. I then provide an overview of AD-E and describe two new change agents- loving-kindness meditation and letter writing-that augment the original AD in service of promoting corrective experiences in the social world that are valued, valuing, and promote the experience of belonging.

"Crying in My Uniform, For Sure": A Qualitative Thematic Analysis of Loss and Grief Among Soldiers After Losing a Comrade in Combat

Recent studies investigate grief among soldiers who experienced combat loss, but little research exists on the qualitative lived experience of such an event. In this study, semi-structured interviews were conducted with soldiers (n = 19) who lost a comrade (3-21 years ago) to delve into their bereavement process. The reflexive thematic analysis of soldiers' accounts identified six main themes: (1) an unexpected and shattering experience; (2) emotional dissociation; (3) detachment from the outside world; (4) group formation; (5) accommodating the bereaved family; and (6) life-long impact. These themes were positioned on four distinct circles relating to the self and the surrounding social systems, indicating how soldiers' grief unfolds and remains encapsulated and disenfranchised. The findings emphasize the value of peer support groups that should be facilitated and encouraged by official bodies-even years after-as part of providing social recognition.

Coping with the long-term impact of civil strife: A grief-centered analysis of Tamil Sri Lankan communities affected by ethnopolitical conflict

Limited research has examined coping mechanisms in response to chronic war-related stressors, as opposed to war-exposure trauma. The current study sought to investigate the types of losses experienced by communities affected by the Sri Lankan conflict, how participants responded to their losses, and what coping mechanisms they employed. Data consisted of interviews from two independent investigations conducted following the end of the conflict in Northern Sri Lanka (total N = 103). Interview transcripts were analyzed using a directed content analysis approach. Participants most frequently described experiencing material loss and loss of loved ones. Relatedly, participants commonly reported experiencing ambiguous loss, that is, living with the uncertainty of their loved one's death. These losses were particularly pronounced by gender, with women experiencing higher rates of loss. Common coping strategies included support-seeking, including informal support from social networks and religion, and formal mental health services. Additionally, participants described a range of longer term coping strategies from establishing a future-oriented cognitive style to a sense of helplessness and resignation. The findings shed light on how conflict-affected groups cope with profound loss. We provide recommendations for how such findings can inform grief-related clinical interventions.

Grief as a Risk Factor for Psychosis: A Systematic Review

PURPOSE OF REVIEW

The assessment of the risk of triggering psychosis upon exposure to grief is a challenge in clinical practice. Adequate diagnosis and early prevention are essential and may be helpful in the evolution of normal grief. We aimed to identify studies exploring grief as a risk factor for developing psychosis.

RECENT FINDINGS

A systematic review of 3 databases (PubMed, EMBASE, and Cochrane Library) was conducted.

RESULTS

In the first approach 618 studies were identified. After the selection process, 15 studies were included in the review. The association between grief and the risk of developing psychosis occurred at younger ages (before 18 years of age) in a first-degree relative and as a consequence of suicide or accidental death. We found that risk factors such as comorbidity, mental problems, unemployment, economic difficulties, and close ties with the deceased have a negative impact on health causing greater vulnerability to psychosis with a risk of developing complicated grief, with statistically significant results regarding the associations between early parental death and the probability of developing psychosis in adulthood.

A unique combination of horror and longing: Traumatic grief in post-October 7, 2023, Israel

On October 7, 2023 (10/7), Hamas militants brutally attacked Israeli towns and villages surrounding the Gaza Strip, resulting in the killing of more than 1100 people, most of whom were civilians slaughtered in their own homes. The killings occurred under highly traumatic circumstances, including shooting, the burning of homes, hunting down people who attempted to escape, and severe sexual assault. Thus, many Israelis today experience a unique mix of both posttraumatic and severe grief reactions. Traumatic grief (TG) is often defined as a condition that results from the death of a significant other and includes symptoms similar to posttraumatic stress disorder (PTSD) that are specifically related to the deceased, such as intrusive thoughts and memories about the deceased and hypervigilance expressed by constantly looking for them or cues associated with them. However, whereas definitions, phenomenological descriptions, and clinical illustrations of PTSD are abundant and widely validated, TG has yet to receive formal diagnostic status. In this paper, we aim to reexamine TG in the context of post-10/7 Israel. We argue that TG is a critical concept for clinicians working in Israel and other conflict-exposed areas of the world today, as it accurately captures the painful mix of grief- and trauma-related symptoms. We also suggest potential explanations for the lack of acknowledgment of TG as a formal diagnosis and discuss the possible role of historical events in the formation of new, relevant psychiatric diagnoses.

A controlled trial of adaptive disclosure-enhanced to improve functioning and treat posttraumatic stress disorder

OBJECTIVE

This is a randomized controlled trial (NCT03056157) of an enhanced adaptive disclosure (AD) psychotherapy compared to present-centered therapy (PCT; each 12 sessions) in 174 veterans with posttraumatic stress disorder (PTSD) related to traumatic loss (TL) and moral injury (MI). AD employs different strategies for different trauma types. AD-Enhanced (AD-E) uses letter writing (e.g., to the deceased), loving-kindness meditation, and bolstered homework to facilitate improved functioning to repair TL and MI-related trauma.

METHOD

The primary outcomes were the Sheehan Disability Scale (SDS), evaluated at baseline, throughout treatment, and at 3- and 6-month follow-ups (Brief Inventory of Psychosocial Functioning was also administered), the Clinician-Administered PTSD Scale (CAPS-5), the Dimensions of Anger Reactions, the Revised Conflict Tactics Scale, and the Quick Drinking Screen.

RESULTS

There were statistically significant between-group differences on two outcomes: The intent-to-treat (ITT) mixed-model analysis of SDS scores indicated greater improvement from baseline to posttreatment in the AD-E group (d = 2.97) compared to the PCT group, d = 1.86; -2.36, 95% CI [-3.92, -0.77], t(1,510) = -2.92, p < .001, d = 0.15. Twenty-one percent more AD-E cases made clinically significant changes on the SDS than PCT cases. From baseline to posttreatment, AD-E was also more efficacious on the CAPS-5 (d = 0.39). These differential effects did not persist at follow-up intervals.

CONCLUSION

This was the first psychotherapy of veterans with TL/MI-related PTSD to show superiority relative to PCT with respect to functioning and PTSD, although the differential effect sizes were small to medium and not maintained at follow-up. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychological predictors of the time perspective: The role of posttraumatic stress disorder, posttraumatic growth, and temporal triggers in a sample of bereaved adults

INTRODUCTION

The process of coping with loss and trauma is inextricably linked with subjective experiences and perceptions of time. The Time Perspective Framework, suggests that temporal frames influence an individual's actions, judgements, and the decisions that they make. Similarly, time perspective has been linked with psychosocial outcomes of trauma and loss (e.g. posttraumatic stress disorder). The aim of this study is to identify factors that may influence survivor's time perspective in order to determine if posttraumatic stress disorder (PTSD), posttraumatic growth (PTG), and temporal triggers (MIT) influenced different time perspective orientations.

METHODS

Data was collected via Qualtrics survey between July 2019 and July 2020. Measures included basic demographic characteristics, posttraumatic stress disorder checklist, posttraumatic growth inventory, an assessment of temporal triggers, and the Zimbardo time perspective inventory. A series of OLS regression analyses were estimated.

RESULTS

PTG was positively associated with future time perspective scores, whereas PTSD was associated with an increase in past negative orientation. The endorsement of temporal triggers like markers in time was negatively associated with present hedonistic scores and positively associated with future time perspective scores. Interestingly, PTSD, PTG and the endorsement of MIT were not associated with present time perspective scores.

DISCUSSION AND IMPLICATIONS

Identifying the relationship between PTSD, PTG, marker in time, and time perspective may offer important insights into treatment modalities that can improve outcomes for bereaved individuals. We discuss limitations of the current analysis and make recommendations for future research.

A cross-sectional examination of sudden-death bereavement in university students

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

When Trauma Survivors with Psychosis Accuse Staff of Sexual Assault in Inpatient Psychiatric Care

Inpatient psychiatric settings are now known settings in which sexual assault can occur. When a trauma survivor with psychosis makes an accusation of sexual assault within an inpatient setting, staff and the institution are frequently not well equipped in how to respond. While there is scant literature on how to proceed in such dilemmas there is even more of a dearth on how to effectively provide mental health services, trauma- and culturally informed care, and how to best engage with the individual so that safety can be maintained, and treatment continue. This article seeks to convey some basic supports for institutional response, theoretical frameworks to enhance understanding and clinical skill, and shifts in care so that trauma-informed and culturally informed care can take place within these complex dynamics. The goal of this paper is to support mental health services and interdisciplinary teams in becoming more effective in navigating these complex situations so that they can honor and respect the trauma survivor and continue to be effective at providing a healing environment.Public Significance Statement: This article offers enhanced understanding of managing risk and balancing trauma-informed care at an institutional and multi-systemic level when inpatients make allegations of sexual assault. Included in this is enhancing understanding from a theoretical framework of the traumatic experiences of clients, assessing needs and offering safety, treatment, and care, while also managing the complex dynamics and services of the organization.

Markers in Time: Expanding Our Concept of Trauma Triggers to Include Subjective Experiences of Time Among Adults Surviving Traumatic Loss

We outline two studies that collected exploratory data on the meaningful time approach and explore the notion of temporal triggers that emerge in the process of coping with traumatic loss. Qualitative data analysis was completed on data gathered from face-to-face interviews as well as open ended responses to an online survey. 35 themes and sub-codes were identified. 30 of these were replicated in both studies. Our data supported the notion of "markers in time" and identified three clear phases to these markers. Participants also noted the consequences of loss on their lives, and the influence of societal and religious approaches to bereavement on their process of coping. Results of this study support a cyclical approach to understanding coping with loss and provides clinicians working with bereaved individuals yet another tool to address the dynamic experience of bereavement.

Prolonged grief, post-traumatic stress, and functional impairment in parents and siblings 8 years after the 2011 Utøya terror attack

Background: Research on bereavement after terrorism is limited and primarily aiming on short-term consequences.Objective: To better understand the long-term health consequences of terrorism, we studied bereaved parents and siblings eight years after the Utøya terrorist attack in Norway. We examined the participants' symptom levels of prolonged grief (PG) and post-traumatic stress (PTS), as well as their psychosocial functioning and employment status.Method: Bereaved parents (n = 88) and siblings (n = 34) aged 19 and above (mean age  = 49.7 years, SD = 13.8 years, 59.8% female) completed the Inventory of Complicated Grief (ICG), the Impact of Event Scale-Revised (IES-R), and the Work and Social Adjustment Scale (WSAS) to assess PG, PTS, and functional impairment, respectively. In addition, information about employment status was obtained. The proportion of participants scoring above recommended thresholds on the ICG, IES-R, and WSAS was calculated. Differences between parents and siblings and gender differences on these measures were examined.Results: In total, 62.3% of the participants had scores on the ICG indicating a risk for prolonged grief, while 45.9% scored over cutoff on the IES. There was a high overlap between symptoms of PG and PTS. Females had significantly higher scores on both the ICG and the IES compared to males. There were no differences between parents and siblings regarding PG and PTS symptoms. One out of three showed severe functional impairment on the WSAS. Approximately 30% of all the bereaved were outside the labour force, and one third of the parents had become unable to work after the terrorist attack.Conclusion: Many bereaved parents and siblings, following the Utøya terror attack, report long-lasting health consequences with symptoms of PG and PTS and functional impairment. The results suggest a need for follow up of bereaved after a terror attack and identify family members in need of health services.

Still Standing Inside: A Local Idiom Related to Trauma among Namibian Speakers of Khoekhoegowab

Euro-centric psychiatric conceptualizations often ignore the interplay of local with universal factors in psychological suffering. Emic, locally focused perspectives can enrich etic knowledge to provide culturally sensitive care and to better elucidate the role of culture in mental illness. This study explored the idiom Tsûsa ǃNaeǃkhais xa hâǃnâ/mâǃnâ/ǂgâǃnâhe hâ (a terrible event has entered a person and remains standing inside), which was understood to relate to experiences of trauma and post-traumatic stress, among speakers of Khoekhoegowab, a southern-African click language. Semi-structured interviews were conducted with 16 participants from six urban and rural communities in Namibia. Questions probed perceptions of the idiom in terms of etiology, course, and risk and resilience factors from a socio-ecological framework. Five key themes were identified using thematic analysis: origin in a shocking event; intrusive recurrence of memories, "it keeps on coming back"; the close interplay between mental and physical suffering; the importance of active engagement in healing through prayer and acceptance; and the role of the community in both alleviating and amplifying distress. Our findings highlight local norms and strategies for adaptive coping, and the benefits of exploring local idioms to elucidate the braiding together of universal and cultural elements in psychological distress.

French-Canadian validation of the Traumatic Grief Inventory-Self Report (TGI-SR)

The Traumatic Grief Inventory Self-Report (TGI-SR), which aims to assess both Persistent Complex Bereavement Disorder and Prolonged Grief Disorder, has been validated in several languages. This study sought to validate the French-Canadian version. We conducted an online survey exploring the impact of the COVID-19 pandemic on grief. With data from 728 participants, the scale demonstrated high internal consistency, correlated significantly with three other scales known to measure similar concepts, and distinguished between groups known to be different. This study supports the use of the TGI-SR French-Canadian version by clinicians and researchers to assess complications of grief.

PTSD Among Shidu Parents in China: The Roles of Personality Types and Social Support

Background: The psychological problems of Shidu Parents (SDP) under the China's One-Child Policy have been documented. The purpose of this study was to investigate the relationships among personality types, social support, and post-traumatic stress disorder (PTSD) in SDP. Methods: The PTSD Checklist-Civilian Version (PCL-C), The Big Five Personality Traits (NEO), and Social Support Revalued Scale (SSRS) were administered to the sample of 149 SDP who were over 50 years old and had lost their only child more than one year ago. Results: Among SDP, mothers were more likely to develop PTSD than fathers (χ² = 11.16, p < 0.01). Parents who were extraverted had a lower risk of developing PTSD-related symptoms (χ² = 8.58, p < 0.01), and the effect of neuroticism was significant (χ² = 23.73, p < 0.01). The more social support parents utilized, the lower the incidence of PTSD (t = 4.56, p < 0.01). The result of multilevel linear regression showed that sex, neuroticism, and objective social support remained significantly different after combining all personality types and social support systems in the same model. Social support partially mediated the relationship between neuroticism and PTSD. Meanwhile, it was a complete mediator between extraversion and PTSD. Conclusions: Female sex/gender, neuroticism, and introversion were risk factors of developing PTSD, while receiving social support protected SDP from developing PTSD symptoms. Losing an only child is undoubtedly an enormous disaster for the family, which has become a huge, unavoidable social problem that must be addressed in China.

Bereavement during the COVID-19 Pandemic: Impact on Coping Strategies and Mental Health

The COVID-19 coronavirus has caused 5.4 million deaths worldwide, including over 800,000 deaths in the United States (as of December 2021). In addition to these staggering statistics, an even greater number of individuals have died from other causes during the COVID-19 pandemic. As a result, a large portion of the global population has faced bereavement during the COVID-19 pandemic and resulting quarantine. The often rapid and unexpected nature of COVID-19 deaths and the presence of pandemic-related stressors and living restrictions make it more difficult for individuals bereaved during the pandemic to implement effective strategies for coping with the loss compared to non-pandemic periods. Quarantine-related constraints (e.g., social distancing, availability of and access to resources) impede coping strategies that have been found to be adaptive after a loss, such as supportive (e.g., seeking emotional and instrumental support) and active (e.g., problem-focused and cognitive reframing) coping, and they augment avoidant strategies (e.g., substance use, denial, and isolation) that have been found to be maladaptive. Poorer mental health outcomes (including prolonged grief disorder; PGD) have been associated with less healthy coping. This article reviews research findings regarding bereavement during the COVID-19 pandemic, discusses the effects of pandemic-related stressors on bereavement coping strategies, and proposes how different types of coping during the pandemic may account for the poorer mental health outcomes described in recent reports. Interventions for promoting adaptive coping strategies and minimizing maladaptive coping strategies are also outlined.

Psychometric Properties of Grief Traits and State Scale for Nurses to Measure Levels of Grief

Frequent exposure to patient deaths prompts nurses to experience grief. Unresolved grief leads to harmful consequences of nurses' mental health and quality of nursing care. A cross-sectional study using an online survey was conducted to determine the psychometric properties of the Grief traits and State Scale for Nurses. Exploratory factor analysis revealed two factors measuring the level of nurses' grief traits (Cronbach's alpha: 0.84) and two factors in grief state (Cronbach's alpha: 0.86). Nurses' feelings of unable to provide good care were associated with a higher risk of grief (odds ratio (OR): 4.30, 95% confidence interval (CI): 1.45-12.75), uncomfortable feeling toward deaths (OR: 11.29, 95%CI: 1.48-85.91), and emotional exhaustion (OR: 7.12, 95%CI: 1.63-30.99). Results indicated that the scale was reliable in determining the levels of their grief. Nurse managers can use the scale to identify their nurses' levels of grief, creating opportunities to influence the resolution of the grief experiences.

The Effect of Traumatic Loss on Posttraumatic Growth Among 2011 Van Earthquake Survivors: The Mediating Role of Posttraumatic Stress

OBJECTIVE

Posttraumatic growth (PTG), defined as a positive change after a traumatic event, has become the subject of various studies, and its relationship with posttraumatic stress symptoms (PTSS) has been extensively investigated. However, studies have indicated differences in the relationship between PTG and PTSS. Therefore, this study aimed to investigate the mediating role of PTSS in the relationship between the number of traumatic losses and PTG among the 2011 Van earthquake survivors.

METHODS

The sample of this study consisted of 917 participants who experienced the 2011 Van earthquake. A personal information form, impact of event scale-revised (IES-R), and posttraumatic growth inventory (PTGI) were used as data collection tools.

RESULTS

Survivors with traumatic loss were found to have higher PTSS and PTG than survivors without traumatic loss. The mean scores of the PTGI subscales were higher among survivors with traumatic loss except for changes in self-perception. A positive correlation was found between IES-R and PTGI total scores. In the regression analysis, it was found that PTSS played a mediating role in the relationship between the number of traumatic losses and PTG.

CONCLUSION

This study revealed that PTG is possible with the presence of PTSS. Mental health professionals assisting survivors with traumatic loss should take the enhancement of PTG into consideration in addition to their efforts to reduce PTSS.

Phone follow up to families of COVID-19 patients who died at the hospital: families' grief reactions and clinical psychologists' roles

A proportion of persons affected by coronavirus disease‐19 (COVID‐19) die and do so in extraordinary circumstances. This can make grief management extremely challenging for families. The Clinical Psychology unit of an Italian hospital offered a bereavement follow‐up call to such families. This study aimed to explore the families' experiences and needs collected during these calls, and the role that the psychologists played through the call. A total of 246 families were called over 3 months. Multiple qualitative methods included: (i) written reports of the calls with relatives of patients who died at the hospital for COVID‐19; (ii) qualitative semi‐structured interviews with psychologists involved in the calls; (iii) observation of psychologists' peer group discussions. A thematic analysis was conducted. Six themes emerged: without death rituals, solitary, unexpected, unfair, unsafe, coexisting with other stressors. Families' reactions were perceived by psychologists as close to a traumatic grief. Families' needs ranged from finding alternative rituals to giving meaning and expressing different emotions. The psychologists played both a social‐institutional and a psychological‐human role through the calls (e.g., they cured disrupted communication or validated feelings and choices). This study highlighted the potential of traumatic grief of families of COVID‐19 victims, and provided indications for supporting them within the space of a short phone call.

Shock, anger and bad deaths in Lihir: A reanalysis of grieving in Papua New Guinea

This paper explores a revelatory moment in fieldwork-the death of a close friend and research participant who died suddenly in suspicious circumstances. Her mourning period challenged my understandings of grief in Lihir. In a previous article I argued that grief in Lihir is resilient and focused on remembering and forgetting, rather than emotions. However this particular mourning period was an emotionally charged space and time. I explore what made this death and grief distinctive, arguing that the nature of her death provoked shock and anger. This paper contributes to an ongoing discussion about how sudden or violent deaths might impact grieving both in the local context, and globally.

Prevalence of post-traumatic symptomatology and anxiety among residential nursing and care home workers following the first COVID-19 outbreak in Northern Italy

The current COVID-19 pandemic has been officially linked to the deaths of hundreds of thousands of people across the globe in just a few months. It is particularly lethal for the elderly in general, as well as for populations residing in long-term stay facilities. By this time, those working and caring for high-risk populations have been exposed to very intense and sudden levels of physical and psychological strain. The situation has taken a particularly tragic turn in residential nursing and care homes (NCH), which were hit hard by the pandemic. In residential NCH, neither residents nor workers tend to have immediate access to the same expertise, medication and equipment as in hospitals, which exacerbates an already tense situation. Among the mental health conditions related to exposure to potentially traumatic events, post-traumatic stress disorder and anxiety are the most prevalent and scientifically recognized. In this survey-based epidemiological study, we test the prevalence of anxiety and post-traumatic symptomatology in residential nursing and care home workers-a group of individuals that has been largely neglected but who nonetheless plays a very important and sensitive role in our society. We do this by focusing on the North of Italy, the most affected region during the first COVID-19 outbreak in Italy. Using a single-stage cluster design, our study returns an estimate for the prevalence of moderate-to-severe anxiety and/or post-traumatic symptomatology of 43% (s.e. = 3.09; 95% CI [37-49]), with an 18% (s.e. = 1.83; 95% CI [14-22]) prevalence of comorbidity among workers of Northern Italian NCH between 15 June and 25 July 2020 (i.e. 12-52 days after the end of national lockdown). Women and workers who had recently been in contact with COVID-19-positive patients/colleagues are more likely to report moderate-to-severe symptoms, with odds ratios of 2.2 and 1.7, respectively.

A human-machine partnered approach for identifying social media signals of elevated traumatic grief in Chicago gang territories

There is a critical need to improve trauma-informed services in structurally marginalized communities impacted by violence and its associated traumatic grief. For community residents, particularly gang-associated youth, repeated exposure to traumatic grief causes serious adverse effects that may include negative health outcomes, delinquency, and future violent offenses. The recent proliferation of digital social media platforms, such as Twitter, provide a novel and largely underutilized resource for responding to these issues, particularly among these difficult-to-reach communities. In this paper, we explore the potential for using a human-machine partnered approach, wherein qualitative fieldwork and domain expertise is combined with a computational linguistic analysis of Twitter content among 18 gang territories/neighborhoods on Chicago's South Side. We first employ in-depth interviews and observations to identify common patterns by which residents in gang territories/neighborhoods express traumatic grief on social media. We leverage these qualitative findings, supplemented by domain expertise and computational techniques, to gather both traumatic grief- and gang-related tweets from Twitter. We next utilize supervised machine learning to construct a binary classification algorithm to eliminate irrelevant tweets that may have been gathered by our automated query and extraction techniques. Last, we confirm the validity, or ground truth, of our computational findings by enlisting additional domain expertise and further qualitative analyses of the specific traumatic events discussed in our sample of Twitter content. Using this approach, we find that social media provides useful signals for identifying moments of increased collective traumatic grief among residents in gang territories/neighborhoods. This is the first study to leverage Twitter to systematically ground the collective online articulations of traumatic grief in traumatic offline events occurring in violence-impacted communities. The results of this study will be useful for developing more effective tools-including trauma-informed intervention applications-for community organizations, violence prevention initiatives, and other public health efforts.

Stillbirth at Term: Grief Theories for Care of Bereaved Women and Families in Intrapartum Settings

Death in intrapartum settings poses a paradox for providers, whose expertise may be limited in assisting bereaved women and families facing the trauma of stillbirth. Many providers are familiar with Kübler-Ross' stage theory of grief; however, more recent theories augment her early work in care of bereaved persons. Through an evolving case study of a couple for whom pregnancy ends in stillbirth at term, 4 theories of grief-loss of the assumptive world, the dual process model, continuing bonds, and complicated grief-are presented to assist intrapartum care providers toward more comprehensive understanding of the complexities of grief responses not fully explained by simple stage theory. These 4 theories are not prescriptive, nor are they comprehensive; however, they are highly relevant and foundational for current understanding of responses and needs of bereaved women and families for whom pregnancy ends in death.

Correlates of grief-related disorders and mental health outcomes among adult refugees exposed to trauma and bereavement: A systematic review and future research directions

BACKGROUND

With conflict driving millions of refugees away from their homes worldwide, there has been an increase in interest in the field of refugee trauma. However, while trauma and bereavement interlink, prior studies have focused on trauma and its related disorders (PTSD) and predictive factors. This paper reviewed up-to-date literature on the prevalence rates of prolonged grief disorder (PGD), its comorbidities, and associated risk factors among adult refugees.

METHOD

We systematically reviewed the literature using five databases (PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, Academic Search Elite, and PubMed). The process of study selection was designed according to PRISMA guidelines.

RESULTS

The initial search generated 126 articles, of which 12 met the inclusion criteria. The pooled prevalence of PGD was 33.2% (95% CI: 15.2-54.2%). Being an older refugee, traumatic and multiple losses implying the death of first-degree relatives appeared to be consistent risk factors for PGD, combined PTSD/PGD, depression, idioms of distress, and functional impairment. PGD, PTSD, and PTSD/PGD intersect on PTSD-intrusions and painful memories.

LIMITATIONS

All included studies adopted a cross-sectional design, thus limiting the understanding of causal pathways.

CONCLUSIONS

Our findings showed that the high prevalence of PGD and related comorbidities were influenced by the load of traumatic circumstances surrounding the death(s). The findings shed light on the current proposed grief-related diagnostic criteria . Psychopathological and transcultural aspects are discussed, and we provide concrete recommendations for improvements to future research in this field.

Traumatic Bereavements: Rebalancing the Relationship to the Deceased and the Death Story Using the Two-Track Model of Bereavement

Bereavements that occur under external traumatic circumstances increase the risk for dysfunction, trauma symptomatology, as well as disordered and prolonged grief. While the majority of individuals who have experienced traumatic bereavements do not meet formal criteria for posttraumatic stress disorder (PTSD), persistent complex bereavement disorder (PCBD), or prolonged grief disorder (PGD), the degree of distress and dysfunction for these bereaved can be quite significant. The assessment and intervention paradigms in use with traumatic bereavements often prioritize the trauma and bypass the centrality of the interpersonal loss. By using a bifocal approach in conceptualizing bereavement, the Two-Track Model of Bereavement (TTMB) rebalances the approach to the class of traumatic bereavements. Track I examines biopsychosocial functioning and symptoms of trauma, and track II focuses on the nature of the ongoing relationship with the deceased and the death story that may also have elements of traumatic response. The model and its application serve to identify both adaptive and maladaptive responses to loss along both axes to optimally focus interventions where needed. The story of the death, the psychological relationship with the deceased, and the presence of biopsychosocial difficulties each have a part to play in assessment and intervention. A case study of assessment and intervention following traumatic bereavement due to suicide illustrates how attention to each of these factors in the TTMB can facilitate change. Ultimately, the relational bond with the deceased is a major vector in grief and mourning. Assessment and intervention with traumatic bereavements require attention to dysfunction and symptoms of trauma as well as to the death story and the state of the relationship to the deceased.

Homicide Survivorship and Suicidality Among Adolescents

Homicide survivorship is linked to depression and trauma symptoms among adolescents, but little is known about associations with suicidality and how these associations intersect with other childhood adversities. This study examined the prevalence of homicide survivorship and associations with suicidality and childhood aversities among a population-based sample of youth using the Healthy Allegheny Teen Survey, a county-wide representative survey of 1,609 youth aged 14 to 19 in Allegheny County, Pennsylvania. Logistic regression models examined associations between homicide survivorship and suicidality, adjusting for (a) demographics and (b) demographics and childhood adversities. In all, 13% of youth were homicide survivors. Black youth experienced a disproportionate burden of traumatic loss. Homicide survivorship was associated with suicide attempts and childhood adversities. Closer attention to the impact of homicide survivorship on youth, mental health sequelae, and co-occurrent childhood adversities may guide interventions to recognize and support youth following traumatic loss.

Patterns of Comorbidity Among Bereaved Family Members 14 Years after the September 11th, 2001, Terrorist Attacks

Studies of terrorism-related deaths are few and mostly focus on short-term effects. To characterize long-term bereavement outcomes, including resilience/recovery and patterns of comorbidity, following the September 11, 2001 (9/11), terrorist attacks, we report mental health conditions and grief-related impairment in 454 9/11 bereaved family members. In addition, the contribution of non-9/11 lifetime traumas, pre-9/11 mental health conditions, post-9/11 interim life events, grief services, income adequacy, and social support were examined. Latent class analyses yielded three groups: healthy, comorbid without PTSD (comorbid/noPTSD), and comorbid with PTSD and impaired (comorbid/PTSD+I). Participants in the healthy group (66.1%) were least likely to meet thresholds for mental conditions, whereas those in the comorbid/noPTSD (21.3%) and comorbid/PTSD+I (12.6%) groups had higher probabilities of meeting depression, grief, and anxiety thresholds. These groups also endorsed more negatively valenced post-9/11 interim life events than the healthy group: comorbid/noPTSD vs. healthy, odds ratio (OR) = 0.84, 95% CI [0.76, 0.94]; comorbid/PTSD+I vs. healthy, OR = 0.85, 95% CI [0.76, 0.96]. Comorbid/PTSD+I was the only group with elevated probabilities of meeting clinical thresholds for PTSD (.64) and grief-related impairment (.94). This group was also more likely to include bereaved parents: comorbid/PTSD+I vs. healthy, OR = 12.96, 95% CI [1.97, 85.41]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 15.55, 95% CI [1.63, 148.41]); and to experience more non-9/11 lifetime traumas: comorbid/PTSD+I vs. healthy, OR = 4.34, 95% CI [1.28, 14.70]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 6.54, 95% CI [1.53, 27.95]. Clinical and community programs should target this high-risk group to identify individuals in need of services.

Predicting Grief Reactions One Year Following a Mass University Shooting: Evaluating Dose-Response and Contextual Predictors

This study identifies risk factors for grief following a mass school shooting. Participants (N = 1,013) completed online questionnaires 3-4 months (Time 1) and 1 year (Time 2) post-shootings. We tested models predicting Time 2 grief reactions, exploring direct and indirect predictive effects of exposure variables (physical and social proximity) through hypothesized peritraumatic mediators (peritraumatic perceived threat to self or others) while controlling for Time 1 grief and posttraumatic stress (PTS) reactions, pretrauma vulnerabilities. Findings demonstrate that closer social proximity predicted higher levels of Time 2 grief, directly and indirectly through increasing peritraumatic perceived threat to others' safety. Physical proximity and peritraumatic threat to self did not predict Time 2 grief reactions. Implications for grief screening instruments and theory building research through identifying risk factors and causal mechanisms are discussed.

Cognitive therapy and eye movement desensitization and reprocessing for reducing psychopathology among disaster-bereaved individuals: study protocol for a randomized controlled trial

Background: Confrontation with a traumatic (e.g. disaster-related) loss is a risk factor for the development of psychopathology, including symptoms of prolonged grief (PG), posttraumatic stress (PTS), and depression. Although interventions have been developed for reducing post-loss psychopathology, more research into the effectiveness of treatment is needed to improve care for bereaved persons. Cognitive therapy (CT) and eye movement desensitization and reprocessing (EMDR) have been shown to be effective in trauma-exposed populations. We hypothesize that CT and EMDR are also effective in reducing symptoms among people exposed to traumatic loss. Objective: In this article we describe the rationale of a randomized controlled trial (RCT) to examine (1) treatment effects of CT and EMDR for reducing PG, PTS, and depression among traumatically bereaved people, and (2) the associations between improvements in PG, PTS, and depression symptoms on the one hand and tentative mechanisms of change, including a sense of unrealness, negative cognitions, avoidance behaviour, and intrusive memories, on the other hand. Method: A two-armed (intervention versus waiting list controls) RCT will be conducted. Participants will be asked to fill in questionnaires prior to treatment, during treatment, and one, 12, and 24 weeks post-treatment. Potential participants are people who have lost one or multiple significant other(s) in the Ukrainian plane disaster in 2014 with clinically significant levels of self-rated PG, PTS, and/or depression. Multiple regression, including analysis of covariance, and multilevel regression analyses will be used. Discussion: There is a need for treatment for psychopathology following traumatic loss. Strengths of this study are the development of a treatment that targets grief and trauma-related complaints and the examination of potential mechanisms of change in CT and EMDR. Bereaved people, clinicians, and researchers could benefit from the results of this study.

Long-term effects of the Entre-os-Rios tragedy on grief and traumatic stress symptoms

In 2001, in Entre-os-Rios, Portugal, a bridge fell on Douro River; all 59 passengers from 1 bus and 3 cars died and 36 bodies have never been recovered. The objective is to reveal the cumulative risk from multiple losses and unrecovered bodies, 10 years after, compared with grievers from road accidents. There are 2 groups of relatives of victims: from this tragedy (n = 20), with at least 1 unrecovered body; and from road traffic accidents (n = 20), with the same time after loss. The prevalence of prolonged grief was 95% and for traumatic stress was 70%. The associated factors of multiple losses and unrecovered bodies increase the long-term risk (relative risk = 1.6 to 2.8; R² = .20 to .28) for prolonged and traumatic grief, providing evidence that the absence of body is an important long-term factor.

The Paradox of Time Post-Pregnancy Loss: Three Things Not to Say When Communicating Social Support

In this essay, I interrogate the role time plays in the three most common social support messages I received post-pregnancy loss. In doing so, I illustrate how our most common "social support" responses to pregnancy loss, while uttered from caring, intentional places of support, can actually serve to marginalize and invalidate experiences of pregnancy loss.

An Interpersonal Neurobiological-Informed Treatment Model for Childhood Traumatic Grief

This article expands an earlier model of the tasks of grieving (1990, [1995], [2001]) by building on science based findings derived from research in attachment theory, neuroscience, interpersonal neurobiology, and childhood traumatic grief (CTG). The proposed treatment model is a prescriptive approach that spells out specific tasks to be undertaken by children suffering traumatic grief under the direction of a therapist who is trained in trauma-informed therapy approaches and draws heavily on the empirically derived childhood traumatic grief treatment model developed by Cohen and Mannarino (2004; Cohen, Mannarino, & Deblinger, 2006). This model expands on their work by proposing specific tasks that are informed by attachment theory research and the interpersonal neurobiological research (Schore, 2003a, 2003b; Siegel, 1999). Particular emphasis is placed on developing a coherent and meaningful narrative since this has been found as a crucial factor in recovery from trauma in attachment research (Siegel, 1999; Siegel & Hartzell, 2003).

Living beyond the Unanticipated Sudden Death of a Partner: A Phenomenological Study

This research project explored grief and its impact upon men and women who have experienced the sudden and unanticipated death of his or her partner.

It included what grief meant to them, how it was manifested in his or her everyday lives and how his or her partner's death had impacted upon his or her relationship with themselves, with others and the world. A Husserlian phenomenological approach was used to explore the experiences of the ten women and five men whose partner had died up to five years prior to being interviewed. The need for the surviving partner to continue to participate in everyday life placed great strain upon the internal resources of the surviving partner. The surviving partner needed to reinvent him or herself, in an attempt to become independent and regain functionality, whilst dealing with the sadness and loss that they had experienced. The surviving partner discovered that a new life order emerged that included hope, optimism, planning for the future and perhaps the prospect of a new relationship. The death of a partner left the surviving partner with a loss that would always be a part of them, with the memories of his or her relationship being maintained within them that will never be replaced by somebody else. The results of this research project reinforce the need for ongoing education of the community in grief and bereavement issues in order to increase the awareness of the support needs of the bereaved person. The length of time and amount of energy required to incorporate the experience into the survivor's life, is greatly underestimated by the community, and perhaps by some of the health and caring professionals. Colonial and hospital based bereavement support services need to be established and be proactive using outreach programs, actively offering the suddenly bereaved partner and family support and information.

Regional cerebral glucose metabolism differentiates danger- and non-danger-based traumas in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is presumably the result of life threats and conditioned fear. However, the neurobiology of fear fails to explain the impact of traumas that do not entail threats. Neuronal function, assessed as glucose metabolism with (18)fluoro-deoxyglucose positron emission tomography, was contrasted in active duty, treatment-seeking US Army Soldiers with PTSD endorsing either danger- (n = 19) or non-danger-based (n = 26) traumas, and was compared with soldiers without PTSD (Combat Controls, n = 26) and Civilian Controls (n = 24). Prior meta-analyses of regions associated with fear or trauma script imagery in PTSD were used to compare glucose metabolism across groups. Danger-based traumas were associated with higher metabolism in the right amygdala than the control groups, while non-danger-based traumas associated with heightened precuneus metabolism relative to the danger group. In the danger group, PTSD severity was associated with higher metabolism in precuneus and dorsal anterior cingulate and lower metabolism in left amygdala (R(2 )= 0.61). In the non-danger group, PTSD symptom severity was associated with higher precuneus metabolism and lower right amygdala metabolism (R(2 )= 0.64). These findings suggest a biological basis to consider subtyping PTSD according to the nature of the traumatic context.

Content Analysis of Select YouTube Postings: Comparisons of Reactions to the Sandy Hook and Aurora Shootings and Hurricane Sandy

This study details an innovative and methodical content analysis of 2,207 YouTube comments from four different YouTube videos (e.g., breaking news or memorials) related to the 2012 Sandy Hook Elementary School and Aurora theater mass shootings and the catastrophic Hurricane Sandy. As expected, YouTube comments associated with the Sandy Hook shootings (particularly those from a memorial video) were especially likely to feature compassion and grief with lessened hostility. This study highlights differing online contexts by which individuals show grief and related emotions following man-made and natural calamities and how-even in an online environment-powerful situational contexts greatly guide behavior.

Professionally Led Peer Support Group Process After the School Shooting in Finland

Background

Traumatic grief is a risk factor for psychological and physiological impairment. In a school shooting incident in Finland, several people lost their lives, and a large number of bereaved family members were at risk for traumatic grief. Psychosocial support for these bereaved was therefore essential, and this article describes a program that was developed for that purpose.

Method

Professionally led peer support group process was provided for the relatives of the deceased in the school shooting in Kauhajoki, Finland, 2008. The 2-year-long process consisted of five weekend gatherings with psychoeducative and group-work elements. The content of the process was based on the existing knowledge of and recommendations for enhancing recovery after a traumatic loss.

Results

On the average, 50 relatives of the deceased in the school shooting participated in the process. The process was based on the principles of (a) timing of the group work and interventions according to stages of bereavement, (b) psychoeducation, awareness rising, and recognizing the signs of posttraumatic symptoms, (c) attachment theory-based elements in parents' and siblings' grief and group work, and (d) encouraging cohesion and strength of families' natural networks and support systems.

Conclusion

Professionally led peer support group process is a trauma-theory-based intervention, which reaches a large number of the bereaved with similar loss. Via group work, psychoeducation, and shared rituals, the bereaved have an opportunity to share and express emotions and experiences, as well as increase their skills in psychological recovery after a violent death of a family member.

What is a "sense of foreshortened future?" A phenomenological study of trauma, trust, and time

One of the symptoms of trauma is said to be a "sense of foreshortened future." Without further qualification, it is not clear how to interpret this. In this paper, we offer a phenomenological account of what the experience consists of. To do so, we focus on the effects of torture. We describe how traumatic events, especially those that are deliberately inflicted by other people, can lead to a loss of "trust" or "confidence" in the world. This undermines the intelligibility of one's projects, cares, and commitments, in a way that amounts to a change in the structure of temporal experience. The paper concludes by briefly addressing the implications of this for how we respond to trauma, as well as offering some remarks on the relationship between trauma and psychosis.

What is a "sense of foreshortened future?" A phenomenological study of trauma, trust, and time

One of the symptoms of trauma is said to be a "sense of foreshortened future." Without further qualification, it is not clear how to interpret this. In this paper, we offer a phenomenological account of what the experience consists of. To do so, we focus on the effects of torture. We describe how traumatic events, especially those that are deliberately inflicted by other people, can lead to a loss of "trust" or "confidence" in the world. This undermines the intelligibility of one's projects, cares, and commitments, in a way that amounts to a change in the structure of temporal experience. The paper concludes by briefly addressing the implications of this for how we respond to trauma, as well as offering some remarks on the relationship between trauma and psychosis.

Posttraumatic stress disorder and prolonged grief in refugees exposed to trauma and loss

BACKGROUND

While a large proportion of conflict-affected populations have been dually exposed to trauma and loss, there is inadequate research identifying differential symptom profiles related to bereavement and trauma exposure in these groups. The objective of this study were to (1) determine whether there are distinct classes of posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD) symptoms in bereaved trauma survivors exposed to conflict and persecution, and (2) examine whether particular types of refugee experiences and stressors differentially predict symptom profiles.

METHODS

Participants were 248 Mandaean adult refugees who were assessed at an average of 4.3 years since entering Australia following persecution in Iraq. PTSD, PGD, trauma exposure, adjustment difficulties since relocation, and English proficiency were measured. Latent class analysis was used to elucidate symptom profiles of PTSD and PGD in this sample.

RESULTS

Latent class analysis revealed four classes of participants: a combined PTSD/PGD class (16%), a predominantly PTSD class (25%), a predominantly PGD class (16%), and a resilient class (43%). Whereas membership in the PTSD/PGD class was predicted by exposure to traumatic loss, those in the PGD class were more likely to have experienced adaptation difficulties since relocation, and individuals in the PTSD class were more likely to have experienced difficulties related to loss of culture and support.

CONCLUSIONS

This study provides evidence that specific symptom patterns emerge following exposure to mass trauma and loss. These profiles are associated with distinct types of traumatic experiences and post-migration living difficulties. These results have substantial public health implications for assessment and intervention following mass trauma.